Provider Demographics
NPI:1124268255
Name:RENFRO, CARL T III (PHD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:T
Last Name:RENFRO
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1310
Mailing Address - Country:US
Mailing Address - Phone:208-263-1736
Mailing Address - Fax:
Practice Address - Street 1:221 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1310
Practice Address - Country:US
Practice Address - Phone:208-263-1736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-170103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical